Highlights & Basics
- Defined as a drug reaction that affects the structure or function of the skin, its appendages, or mucous membranes.
- Common adverse skin reactions to systemic drugs include: maculopapular skin reactions; urticaria and angioedema; and the spectrum of skin lesions including fixed drug eruptions, erythema multiforme, DRESS (drug reaction with eosinophilia and systemic symptoms; also called drug hypersensitivity syndrome), Stevens-Johnson syndrome, and toxic epidermal necrolysis. Together these account for the majority of all drug-induced skin manifestations.
- Any drug can cause a predictable or unpredictable reaction; those commonly implicated include beta-lactam antibiotics, muscle relaxants used in anesthesia, sulfonamides and structurally related drugs, contrast media, and gelatins.
- Withdrawal of the suspected drug is essential. A history of previous reactions to drugs should always be taken before prescribing.
- Skin tests (prick tests, intradermal tests, patch tests) can occasionally be useful in diagnosing allergic reactions retrospectively, especially contact dermatitis.
Quick Reference
History & Exam
Key Factors
Other Factors
Diagnostics Tests
Treatment Options
Definition
Epidemiology
Etiology
Pathophysiology
Images
Palmar target lesions in erythema multiforme
Blistering targetoid lesions on the trunk, carbamazepine induced Stevens-Johnson syndrome
Oral and mucosal ulcerations, carbamazepine induced Stevens-Johnson syndrome
Drug exanthem due to phenytoin
Typical lesions seen in acute or chronic urticaria
Angioedema of the lips in a patient who also has urticaria
Stevens-Johnson syndrome: epidermal loss on soles of feet
Initial phase of toxic epidermal necrolysis with diffuse erythema and vesicles that will evolve to full epidermal necrosis
A 17-year-old male patient diagnosed with Stevens-Johnson syndrome due to azitromicine. Erosions and crusts on the lips with diffuse ulcers on the tongue
A 5-year-old female patient with toxic epidermal necrolysis with three suspected drugs (penicillin, ibuprofen, and acetaminophen)
The Naranjo scoring system
Citations
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Gell PG, Coombs RRA, eds. Clinical aspects of immunology. 1st ed. Oxford: Blackwell; 1963.
Bigby M, Jick S, Jick H, et al. Drug-induced cutaneous reactions: a report from the Boston Collaborative Drug Surveillance Program on 15,438 consecutive inpatients, 1975 to 1982. JAMA. 1986 Dec 26;256(2):3358-63.[Abstract]
Kuokkanen K. Drug eruptions: a series of 464 cases in the Department of Dermatology, University of Turku, Finland, during 1966-1970. Acta Allergol. 1972 Dec;27(5):407-38.[Abstract]
Aronson JK, Ferner RE. Clarification of terminology in drug safety. Drug Saf. 2005;28(10):851-70.[Abstract]
Khan DA, Banerji A, Blumenthal KG, et al. Drug allergy: a 2022 practice parameter update. J Allergy Clin Immunol. 2022 Dec;150(6):1333-93.[Abstract][Full Text]
Naranjo CA, Busto U, Sellers EM, et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther. 1981 Aug;30(2):239-45.[Abstract]
Hill AB. The environment and disease: association or causation? Proc R Soc Med. 1965 Jan;58(1):295-300.[Abstract][Full Text]
Howick J, Glasziou P, Aronson JK. The evolution of evidence hierarchies: what can Bradford Hill's 'guidelines for causation' contribute? J R Soc Med. 2009 May;102(5):186-94.[Abstract][Full Text]
National Institute for Health and Care Excellence. Drug allergy: diagnosis and management. September 2014 [internet publication].[Full Text]
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